Development Research Group, The World Bank, Washington, DC, USA.
School of Community Health Sciences, University of Nevada, Reno, NV, USA.
Lancet Glob Health. 2019 Sep;7(9):e1257-e1268. doi: 10.1016/S2214-109X(19)30317-1.
Evidence from efficacy trials suggests that lipid-based nutrient supplementation (LNS) and home visits can be effective approaches to preventing chronic malnutrition and promoting child development in low-income settings. We tested the integration of these approaches within an existing, large-scale, community-based nutrition programme in Madagascar.
We randomly allocated 125 programme sites to five intervention groups: standard-of-care programme with monthly growth monitoring and nutrition education (T0); T0 plus home visits for intensive nutrition counselling through an added community worker (T1); T1 plus LNS for children aged 6-18 months (T2); T2 plus LNS for pregnant or lactating women (T3); or T1 plus fortnightly home visits to promote and encourage early stimulation (T4). Pregnant women (second or third trimester) and infants younger than 12 months were enrolled in the trial. Primary outcomes were child growth (length-for-age and weight-for-length Z scores) and development at age 18-30 months. Analyses were by intention to treat. The trial was registered with the ISRCTN registry, number ISRCTN14393738.
The study enrolled 3738 mothers: 1248 pregnant women (250 women in each of the T0, T1, T2, and T4 intervention groups and 248 in the T3 intervention group) and 2490 children aged 0-11 months (497 children in T0, 500 in T1, 494 in T2, 499 in T3, and 500 in T4) at baseline who were assessed at 1-year and 2-year intervals. There were no main effects of any of the intervention groups on any measure of anthropometry or any of the child development outcomes in the full sample. However, compared with children in the T0 intervention group, the youngest children (<6 months at baseline) in the T2 and T3 intervention groups who were fully exposed to the child LNS dose had higher length-for-age Z scores (a significant effect of 0·210 SD [95% CI -0·004 to 0·424] for T2 and a borderline effect of 0·216 SD [0·043 to 0·389] for T3) and lower stunting prevalence (-9·0% [95% CI -16·7 to -1·2] for T2 and -8·2% [-15·6 to -0·7] for T3); supplementing mothers conferred no additional benefit.
LNS for children for a duration of 12 months only benefited growth when it began at an early age, suggesting the need to supplement infants at age 6 months in a very low-income context. The lack of effect of the early stimulation messages and home visits might be due to little take-up of behaviour-change messages and delivery challenges facing community health workers.
Eunice Kennedy Shriver National Institutes of Child Health and Human Development, Strategic Impact Evaluation Fund, World Bank Innovation Grant, Early Learning Partnership Grant, World Bank Research Budget, Japan Nutrition Trust Fund, Power of Nutrition, and the National Nutrition Office of Madagascar.
疗效试验的证据表明，基于脂质的营养补充剂（LNS）和家访可能是在低收入环境中预防慢性营养不良和促进儿童发育的有效方法。我们在马达加斯加现有的大型社区营养方案中测试了这些方法的整合。
我们将 125 个方案点随机分配到五个干预组：每月进行生长监测和营养教育的标准护理方案（T0）；T0 加通过额外的社区工作者进行强化营养咨询的家访（T1）；T1 加 6-18 个月儿童的 LNS（T2）；T2 加妊娠或哺乳期妇女的 LNS（T3）；或 T1 加两周家访以促进和鼓励早期刺激（T4）。试验招募了妊娠（第二或第三个三个月）和 12 个月以下的婴儿。主要结局是儿童生长（年龄别身长和身长别体重 Z 分数）和 18-30 个月时的发育。分析采用意向治疗。该试验在 ISRCTN 注册处注册，编号 ISRCTN14393738。
该研究共纳入了 3738 位母亲：1248 位孕妇（T0、T1、T2 和 T4 干预组各有 250 位，T3 干预组有 248 位）和 2490 位 0-11 个月大的儿童（T0 组有 497 位，T1 组有 500 位，T2 组有 494 位，T3 组有 499 位，T4 组有 500 位），他们在基线时接受了评估，并在 1 年和 2 年间隔时进行了评估。在全样本中，任何干预组都没有对任何人体测量学指标或任何儿童发育结果产生主要影响。然而，与 T0 干预组的儿童相比，充分接触儿童 LNS 剂量的 T2 和 T3 干预组中年龄最小（基线时<6 个月）的儿童身高年龄 Z 分数更高（T2 组有显著效果，为 0.210 SD [95%CI-0.004 至 0.424]，T3 组有边缘效果，为 0.216 SD [0.043 至 0.389]），且生长迟缓发生率较低（T2 组为-9.0% [95%CI-16.7 至-1.2]，T3 组为-8.2% [-15.6 至-0.7]）；给母亲补充营养没有额外的好处。
仅对儿童进行为期 12 个月的 LNS 补充，当它在早期开始时才有利于生长，这表明在非常低收入的环境中，6 个月大的婴儿需要补充营养。早期刺激信息和家访没有效果，可能是因为行为改变信息的接受度低，社区卫生工作者面临着提供信息的挑战。
美国国立卫生研究院儿童健康与人类发展部，战略影响评估基金，世界银行创新赠款，早期学习伙伴赠款，世界银行研究预算，日本营养信托基金，营养力量和马达加斯加国家营养办公室。
